Open defecation solves the child mortality puzzle among Indian Muslims

Child mortality is lower among Muslims despite being poorer and less educated

In India, Hindus are, on average, richer and more educated than Muslims. But oddly, Hindus' child mortality rate is much higher. All observable factors say Hindus should fare better, but they don't. Economists refer to this as the Muslim mortality puzzle.

In a new study, researchers believe that they may have found a solution to the puzzle. And, surprisingly, the solution lies in a single factor referred to as "a particular sanitation externality"—open defecation.

Asian enigma

As far back as 1925, when India was still a British colony with a population of 280 million, Mahatma Gandhi said, "Sanitation is more important than independence." Although his concern then was less to do with public health and more to do with human dignity, heeding his words would have improved—and in many cases saved—the lives of millions who were yet to be born.

Today more than 600 million Indians defecate in the open. But India is not the only country to face this problem—15 percent of the world's population does that. Recent research has shown that open defecation leads to higher child mortality rates and stunted growth. Some regions in India do worse than sub-Saharan Africa on those parameters.

Dean Spears at Delhi School of Economics had been studying the effects of open defecation in India, which led him to a solution for the "Asian enigma"—why are Indian children shorter, on average, than African children, even though people are poorer, on average, in Africa. The height of children is one of the most important measures of their wellbeing, and Spears and his colleagues found that it is severely affected by open defecation.

Poor children play in the same fields where their friends and parents relieve themselves. Disease-causing bacteria and parasites then end up on these children's hands and feet, eventually landing in their food and drink. While some of these bugs make people sick, the symptoms of others may not be visible until later in life. Many years of exposure to such bugs can cause enetropathy—a chronic intestinal problem that prevents proper absorption of calories and nutrients, leading to stunted growth.

Disease transmission via open defecation has not been unique to the developing world. Between 1910 and 1915, the Rockefeller Foundation spent millions to eradicate hookworm infection in southern US. The disease is spread via human feces, and barefoot children came in contact with it while using unsanitary outhouses.

Religious issues

When Spears, along with Arabinda Ghosh and Oliver Cumming, published their work on stunted growth, they relied on data derived from the HUNGaMA (hunger and malnutrition) survey, which looked at thousands of people in a few representative districts throughout India. For the new study, however, a more reliable data source is the government-run National Family Health Survey, which collects information from women aged 13 to 49. Apart from personal information, the survey asks them to report birth and death histories, as well as information about household assets, infrastructure, and health habits (including information about toilet facilities and their usage). The database Spears and his team selected had about 310,000 Hindu and Muslim children from three survey rounds conducted in 1992, 1998, and 2005.

Religious communities may settle in a certain part of a village or town in India. While India boasts of people of many different religions, Hindus and Muslims make up the bulk of the population, which means that they were the easiest groups to study.

Using all those factors, statistical analysis revealed that open defecation may contribute to the difference in child mortality rates. "We show that the entire gap between Muslim and Hindu child mortality can be accounted for by a particular kind of sanitation externality," wrote Spears and Michael Geruso, professor of economics at the University of Texas at Austin, in their working paper. They found that Muslims, regardless of income, were 20 percent more likely to use toilets than Hindus.

More convincingly, the analysis showed that moving from a locality where everybody defecates in the open to a locality where no one does is associated with a larger difference in child mortality than moving from the bottom quintile of asset wealth to the top quintile.

"I am not surprised that there are differences among religious groups," said Jeroen Ensink, a lecturer in public health engineering at the London School of Hygiene and Tropical Medicine who has worked on sanitation practices in India.

Could differences in open defecation be just one factor among other differences in general hygiene practices? Probably not. Spears and Geruso found no systematic differences among the religious groups when it came to hand washing or water purification techniques.

It was important to be sure that there were no other systematic differences among religious practices of Hindus and Muslims that could have contributed. In "the rare places where Hindus are less likely to defecate in the open than Muslims," Spears and Geruso found that the advantage reverses—child mortality among Hindus turns out to be lower than that among Muslims.

The analysis also showed that Hindu households residing in villages with majority Muslim population experienced lower child mortality than Hindus living among other Hindus. The reverse also held true—Muslims living among Hindus had higher mortality rates than if they lived among Muslims. "This is consistent with the findings that it is not your own hygiene practices but that of your neighbors which matter most," said Sandy Cairncross, a professor of environmental health also at the London School of Hygiene and Tropical Medicine who has worked in India to increase toilet use.

A positive sign is that Spears and Geruso found breastfeeding could counteract the negative effects of poor sanitation. The reason is that breastfed children are less exposed to disease-causing germs directly through contaminated water and food, even if the mother was exposed to those germs directly.

This study only draws a correlational link between open defecation and child mortality rates among religious groups. "The causes could lie in the differences among Hindu and Muslim religious codes," said Ensink.

For a causal link to be established, an experiment will have to be done where a select group is provided with more toilets and health information that increases their use of them. But such a study won't pass ethical committees, because the benefits of toilet use are clear. It is not ethical to knowingly deprive any community of these benefits, which means it is not ethical to have a control group.

Behavioral change

What is clear is that reducing the number of those who defecate in the open will have a large impact on the health of individuals and the communities they live in. However, changing behavior, even if the benefits are so obvious, is easier said than done. The Indian government has spent millions to build toilet facilities through programs such as Total Sanitation Campaign, but they often remain unused or are repurposed.

"Just because they have a latrine, people don't stop defecating in the open," said Cairncross. His work in Asia and Africa has revealed that people don't install toilet facilities for health reasons. Instead the common reasons cited are security, social prestige, and dignity.

While education can help change behavior and hygiene practices, it is a slow process. The problem is so large and so urgent that Ensink thinks that policies need to be set in place to drive behavioral change.

It strikes me that India needs to start dealing with its shit, which is ultimately both a viable energy and fertilizer resource, if it's collected without all kinds of toxic crap, as poop only. Then fermenting (methane production for energy) and composting would make it into safe fertilizer for food crops. This stuff should really not be complicated, even without plumbing.

I don't think ethics rule out a randomized trial. What has typically been done is that some funds are allocated for an improvement, but its not enough to help everyone. You then use randomization as part of the allocation of funds. Including a randomization step in the allocation has been done numerous times and seems to pass ethics review.

Also, it is discongruent to state no causal link has been established, but that "What is clear is that reducing the number of those who defecate in the open will have a large impact on the health of individuals and the communities they live in." That is precisely what a causal link is. So it is not clear. "Reducing open defecation is a promising avenue for improving health", might be better phrasing.

"Just because they have a latrine, people don't stop defecating in the open," said Cairncross. His work in Asia and Africa has revealed that people don't install toilet facilities for health reasons. Instead the common reasons cited are security, social prestige, and dignity.

A reminder that we are not the completely rational creatures we would like to believe.

It's all a matter of what you are accustomed to. While I have not been to India (yet), I have spent extended periods of time in other areas of the world where raw sewage runs freely in the open and refuse of all types (including rotting carcasses) is just allowed to pile up in the open. At first, the smell can be completely overwhelming, especially if it is hot, humid, and still but, after awhile, you just get inured to it.

I'm not terribly surprised; we see evidence of this historically. Societies that placed a higher emphasis on cleanliness tended to be larger and generally healthier. It even shows up elsewhere; successful armies tended to have good latrines.

It's a matter of socialisation, though, which is hell to change. There's a lot of inertia in human civilization.

It strikes me that India needs to start dealing with its shit, which is ultimately both a viable energy and fertilizer resource, if it's collected without all kinds of toxic crap, as poop only. Then fermenting (methane production for energy) and composting would make it into safe fertilizer for food crops. This stuff should really not be complicated, even without plumbing.

This reminded me of how Muhammed (the prophet of islam) quotes from the old testament, idk how much and if health codes setup in the Mosaic law (such as quarantine procedures, and specifically defecating far away from your camp into a latrine and then burying it) are even used by modern day Muslims or if its just "put your left foot in, put your right foot out, praise Allah and shake it all about, and that's what its all about!"

I can't say I know much about it but I have seen two fellows in two different towns in the same country come out of squat toilets in a public building. They did a cursory handwash (well, not much different from many other people...) and then they washed the soles of their feet. Just a quick wipe on the bottom of the shoe with a wet hand. This followed the initial handwashing and there was no handwashing subsequent to the shoe wipe.

I mention 'two towns' because, although I saw only a handful of public restrooms, I take the practice to not be unheard of and terribly unusual for the area. They have different ways of going about business. The foot wiping, they likely thought no more of than an American washing hands yet then blowing the nose. The comparison only of the improper order of operation, of course...

I can't say any of this necessarily has to do with being Muslim, though.Very different stuff, though.

Also, it is discongruent to state no causal link has been established, but that "What is clear is that reducing the number of those who defecate in the open will have a large impact on the health of individuals and the communities they live in." That is precisely what a causal link is.

The specific micro organism responsible for the difference hasn't been identified (the cause), only a bathroom habit behavior that must be associated with the infection vector (exposure to the cause).

So, are you saying they curry favor to conspicuous crapping? I wonder if this is just a drop in the bucket, or if a massive dump in these stats will create a backsplash that will bowl us over. If we can find a way to flush these public poopers, people may start to once again give a shit.

Very cool, thanks for posting this. I have witnessed this difference first hand each time I visit India.

The newly elected prime minister, a Hindu by the name of Modi, had as his platform, "Toilets first, temples later." There is a lot of support for him among Hindus and hopefully this can bring the change needed to make the population healthier as a whole.

This reminded me of how Muhammed (the prophet of islam) quotes from the old testament, idk how much and if health codes setup in the Mosaic law (such as quarantine procedures, and specifically defecating far away from your camp into a latrine and then burying it) are even used by modern day Muslims or if its just "put your left foot in, put your right foot out, praise Allah and shake it all about, and that's what its all about!"

I can't say I know much about it but I have seen two fellows in two different towns in the same country come out of squat toilets in a public building. They did a cursory handwash (well, not much different from many other people...) and then they washed the soles of their feet. Just a quick wipe on the bottom of the shoe with a wet hand. This followed the initial handwashing and there was no handwashing subsequent to the shoe wipe.

I mention 'two towns' because, although I saw only a handful of public restrooms, I take the practice to not be unheard of and terribly unusual for the area. They have different ways of going about business. The foot wiping, they likely thought no more of than an American washing hands yet then blowing the nose. The comparison only of the improper order of operation, of course...

I can't say any of this necessarily has to do with being Muslim, though.Very different stuff, though.

Well, in fairness, here in the US some people will thoroughly wash their hands after any toilet use, and others will defecate and just walk out.

In theory, all of the Abrahamic religions (Judaism, Christianity, Islam, and the various offshoots) have sanitary requirements. But when you start involving humans, "requirements" are often held to wildly differing standards.

As well, what hand did they "wash" their feet with? I think Muslims won't eat and such with their left hand, so if they washed with that one it might not significantly effect overall hygeine.

I can't say I know much about it but I have seen two fellows in two different towns in the same country come out of squat toilets in a public building. They did a cursory handwash (well, not much different from many other people...) and then they washed the soles of their feet. Just a quick wipe on the bottom of the shoe with a wet hand. This followed the initial handwashing and there was no handwashing subsequent to the shoe wipe.

I mention 'two towns' because, although I saw only a handful of public restrooms, I take the practice to not be unheard of and terribly unusual for the area. They have different ways of going about business. The foot wiping, they likely thought no more of than an American washing hands yet then blowing the nose. The comparison only of the improper order of operation, of course...

I can't say any of this necessarily has to do with being Muslim, though.Very different stuff, though.

As American born I think that order is strange too. But as someone who has used those types of toilets in some of the most unsanitary places, and most densely populated places, I can say that those squat toilets, as big as they are, are occasionally still missed by previous users (!!) and then when you go to clean there is some splashing as much as you try not to. So sometimes there is a need to throw water on your feet too.

Which is another point -- water is used for drinking first and washing later; how many of these towns, even with open defection, could benefit from water supply for hand washing too, I wonder?

I had to go 'seriously' as I read this. Open defecation? What is this, the BC25000's? Even as far back as BC days, they knew that openly defecating was asking for problems and dug a hole for their toilet.

I don't think ethics rule out a randomized trial. What has typically been done is that some funds are allocated for an improvement, but its not enough to help everyone. You then use randomization as part of the allocation of funds. Including a randomization step in the allocation has been done numerous times and seems to pass ethics review.

Also, it is discongruent to state no causal link has been established, but that "What is clear is that reducing the number of those who defecate in the open will have a large impact on the health of individuals and the communities they live in." That is precisely what a causal link is. So it is not clear. "Reducing open defecation is a promising avenue for improving health", might be better phrasing.

Praise Jesus -- you are exactly right.

I would add that spending billions on interventions that have no causally valid evidence of effectiveness is the thing that is unethical.

The only way they can enact change (if promoting it's benefits doesn't work), is to ostracize the people and the act of defecating in public. Make people focus on how poorly it affects them and others, and make those that do it feel self conscious about doing something taboo.

The problem right now is it's considered "acceptable". They need to change that viewpoint so that when they think of defecating in public, it's considered the absolute worst thing to do.

"That is the most pungent thing I have ever smelled and I am from India!" -Apu

I kid, well sort of. There are many wonderful places and people in India. It's long since been known that better sanitation means better health, so part of me reads this study and thinks, "Well, of course.", but perhaps it will be valuable as it provides further evidence that the lack of proper sanitation is killing Indian children. Maybe this will help to spur change. The "think of the children" argument works very well when it is used reasonably.

I don't think ethics rule out a randomized trial. What has typically been done is that some funds are allocated for an improvement, but its not enough to help everyone. You then use randomization as part of the allocation of funds. Including a randomization step in the allocation has been done numerous times and seems to pass ethics review.

Also, it is discongruent to state no causal link has been established, but that "What is clear is that reducing the number of those who defecate in the open will have a large impact on the health of individuals and the communities they live in." That is precisely what a causal link is. So it is not clear. "Reducing open defecation is a promising avenue for improving health", might be better phrasing.

Don't forget the whole rape thing.India is a fucked up place to live. The whole 'cast' system? WTF.

I basically agree, but I think it's worth pointing out that illiberal, bass-ackwards attitudes and behaviors exist all over the world, including in places like the United States. I read a story about red neck dufasses bringing automatic weapons into restaurants in Texas as some kind of bizzaro protest in favor of the right to carry guns openly in public. I don't know what's worse -- some right wing a-hole walking in with an AK-47 while I'm eating my steak, or walking out into the parking lot and seeing an Indian crapping in the parking lot. I'm glad I don't have to deal with either one.

Don't forget the whole rape thing.India is a fucked up place to live. The whole 'cast' system? WTF.

I basically agree, but I think it's worth pointing out that illiberal, bass-ackwards attitudes and behaviors exist all over the world, including in places like the United States. I read a story about red neck dufasses bringing automatic weapons into restaurants in Texas as some kind of bizzaro protest in favor of the right to carry guns openly in public. I don't know what's worse -- some right wing a-hole walking in with an AK-47 while I'm eating my steak, or walking out into the parking lot and seeing an Indian crapping in the parking lot. I'm glad I don't have to deal with either one.

Off topic, but I never understood the "I'm acting like an ass to exercise my rights" mentality. Yes, you have the right to bring a legal weapon into a restaurant. You have a right to cuss in front of kids too, but that doesn't make it all right and you still deserve scorn.

As American born I think that order is strange too. But as someone who has used those types of toilets in some of the most unsanitary places, and most densely populated places, I can say that those squat toilets, as big as they are, are occasionally still missed by previous users (!!) and then when you go to clean there is some splashing as much as you try not to. So sometimes there is a need to throw water on your feet too.

...

Oh, I understood the reason behind the shoe rinse...! I worked out a strategic plan for my activities. I was not in a country without any western toilets. I couldn't really go native. Just me... :^|

... As well, what hand did they "wash" their feet with? I think Muslims won't eat and such with their left hand, so if they washed with that one it might not significantly effect overall hygeine.

Mmm, both hands. Standing, left leg raised and crossed in front of body so left sole is on right side. Right hand used for that foot. Reversed procedure for right foot. They just used the hand convenient for the task. They did not raise their foot behind them so the sole was near their fanny. I think the way they did it would be most convenient.

This reminded me of how Muhammed (the prophet of islam) quotes from the old testament, idk how much and if health codes setup in the Mosaic law (such as quarantine procedures, and specifically defecating far away from your camp into a latrine and then burying it) are even used by modern day Muslims or if its just "put your left foot in, put your right foot out, praise Allah and shake it all about, and that's what its all about!"

I can't say I know much about it but I have seen two fellows in two different towns in the same country come out of squat toilets in a public building. They did a cursory handwash (well, not much different from many other people...) and then they washed the soles of their feet. Just a quick wipe on the bottom of the shoe with a wet hand. This followed the initial handwashing and there was no handwashing subsequent to the shoe wipe.

I mention 'two towns' because, although I saw only a handful of public restrooms, I take the practice to not be unheard of and terribly unusual for the area. They have different ways of going about business. The foot wiping, they likely thought no more of than an American washing hands yet then blowing the nose. The comparison only of the improper order of operation, of course...

I can't say any of this necessarily has to do with being Muslim, though.Very different stuff, though.

I know for a fact that miiddle-east people (not inly muslims, but also christians and other religions, though I don't know if israelis do this) never uses their left hands for eating as it is used to clean themselves after going to the bathroom. l

It strikes me that India needs to start dealing with its shit, which is ultimately both a viable energy and fertilizer resource, if it's collected without all kinds of toxic crap, as poop only. Then fermenting (methane production for energy) and composting would make it into safe fertilizer for food crops. This stuff should really not be complicated, even without plumbing.

It's not that easy, well at least with the fertilizer aspect. There's a lot of potential contaminants in human feces, some of which are human transferable pathogens and pharmaceuticals which are probably the hardest to remove. Heavy metals might be an issue too.

I remember reading that one case of Dalits is responsible for cleaning up after other people's poop. The description I read went like this: Someone is walking on the sidewalk and really needs to go. They stop off the sidewalk (but might still be in a visible place) and do their business. While they're squatting, a Dalit of this particular caste comes up and waits for them to finish. When the person finishes they give the Dalit some rupees, and the Dalit cleans the sidewalk (with or without tools). Can someone who's visited testify to the validity of this description?

This reminded me of how Muhammed (the prophet of islam) quotes from the old testament, idk how much and if health codes setup in the Mosaic law (such as quarantine procedures, and specifically defecating far away from your camp into a latrine and then burying it) are even used by modern day Muslims or if its just "put your left foot in, put your right foot out, praise Allah and shake it all about, and that's what its all about!"

I think you're misreading the article. The people openly defecating are not the Muslims (mostly) - it's the Hindu. I'm not familiar with Hindu religious practices, but I am pretty sure they don't include Mosaic sanitation laws. Islamic laws are more likely to do so, because it IS an Abrahamic religion and did carry some of the same laws into the Qu'ran.

[Disclaimer - I'm not a Muslim. Nor am I a Hindu. But I stayed at a Holiday Inn Express last night.]